JACC gol. 25, No. 6 1465 May 1995:1465-9 ACP/ACC/AHA TASK FORCE STATEMENT

Clinical Competence in A Statement for Physicians From the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology

LEAD AUTHOR CHARLES FISCH, MD, FACC

TASK FORCE MEMBERS

THOMAS J. RYAN, MD, FACC, FACP, Chairman SANKEY V. WILLIAMS, MD, FACP, Immediate Past Chairman JAMES L. ACHORD, MD, FACP JAMES LEONARD, MD, FACP MASOOD AKHTAR, MD, FACC JOHN B. O'CONNELL MD, FACC MICHAEL H. CRAWFORD, MD, FACC ROBERT A. O'ROURKE, MD, FACC GOTI'LIEB C. FRIESINGER II, MD, FACC WILLIAM A. REYNOLDS, MD, FACP ELMER J. HOLZINGER, MD, FACP PATRICK J. SCANLON, MD, FACC FRANCIS J. KLOCKE, MD, FACC ROBERT C. SCHLANT, MD, FACC PETER R. KOWEY, MD, FACC DONALD E. WARE, MD, FACP RISA J. LAVIZZO-MOUREY, MD, FACP

The selective granting of clinical staff privileges to physicians is cardiography are specified; whenever possible, these are based one of the primary mechanisms used by institutions to uphold on published data linking these factors with competence in the quality of care. The Joint Commission on the Accreditation certain procedures and, in the absence of such data, on of Healthcare Organizations requires that the granting of consensus of expert opinion. They are applicable to any initial or continuing medical staff privileges be based on practice setting and can accomodate a variety of pathways that assessments of applicants against professional criteria that are physicians might take to competence in the performance of specified in the medical staff bylaws. Physicians themselves are specific procedures (see also Guide to the use of ACP state- thus charged with identifying the criteria that constitute pro- ments on clinical competence. Ann lntern Med 1987;107:588- fessional competence and with evaluating their peers on the 9). basis of such criteria. Yet the process of evaluating a physi- cian's knowledge and competence is often constrained by the evaluator's own knowledge base and ability to elicit the appropriate information, a problem that is compounded by the Overview of the Procedure growing number of highly specialized procedures for which Introduced in 1903 by Einthoven, electrocardiography is the privileges are requested. most commonly used laboratory procedure for the diagnosis of This recommendation is one in a series developed to assist heart disease. As a record of electrical activity of the heart, it in the assessment of physician competence on a procedure- is a unique technology that provides information not readily specific basis. The minimal education, training, experience and obtained by other methods. cognitive skills necessary for proper interpretation of electro- The procedure is safe, there being essentially no risk to the patient; it is simple and reproducible; the record lends itself to serial studies; and the relative cost is minimal. The electrocar- Clinical Competence in Electrocardiography has been approved by the American College of Physicians Board of Regents, the American College of diogram (ECG) has the following utilities: It may serve as an Cardiology Board of Trustees and the American Heart Association Steering independent marker of myocardial disease; it may reflect Committee. This statement is being published simultaneously, in Journal of the anatomic, electrophysiologic, metabolic and hemodynamic al- American College of Cardiolo~" and Circulation. Address for reprints: Educational Services, American College of Cardiology, terations; it provides information that is often essential for the 9111 Old Georgetown Road, Bcthesda, Maryland 20814. proper diagnosis of and therapy for a variety of cardiac

,~3 1995 by the American College of Cardiology, American ltcarl Association and American College of Physicians 0735-1097/95/$9.50 0735-1097(95)00059-D 1466 FISCH ET AL. JACC Vol. 25, No. 6 ACP/ACC/AHA TASK FORCE STATEMENT May 1995:1465-9 disorders; and it is without equal as a method for the diagnosis 10th Bethesda Conference on optimal electrocardiography (5), of . Electrocardiography is the procedure of first data extracted from published reports and the opinion of the choice in patients presenting with chest pain, dizziness or ACP/ACC/AHA Task Force on Cardiology of the American syncope, symptoms that may be predictive of one or both of the College of Physicians' Clinical Privileges Project. two leading and potentially catastrophic cardiovascular Recommendations on maintenance of competence are disorders--sudden death or . Electrocar- based on the expert opinion of the ACP/ACC/AHA Task diographic abnormalities also may be the first indicators of Force on Cardiology of the American College of Physicians' life-threatening side effects of drugs and of severe metabolic or Clinical Privileges Project. electrolyte disturbance and occasionally the only sign of myo- cardial disease, such as "asymptomatic" myocardial infarction in the aged (1). Indications, Contraindications and Appropriate and accurate use of the ECG requires that its Complications sensitivity and specificity be understood and considered in the Although there may be a difference of opinion as to interpretation of the recording. This is somewhat more com- indications for an ECG study in a given clinical setting, largely plex for the ECG than for many other laboratory tests because because of lack of definitive data, some of the settings in which the ECG is composed of a number of waveforms each with its an ECG is indicated include the following: own sensitivity and specificity and each influenced differently by a variety of pathologic and pathophysiologic factors. 1. For the diagnosis of overt or suspected cardiovascular When considering the sensitivity and specificity of the ECG disease. Follow-up recordings are indicated when there is a it is important to recognize that the ECG is a record of change in clinical status. electrical activity. Consequently, diagnoses of structural (i.e., 2. For assessing the results of therapy. myocardial infarction, hypertrophy) or pathophysiologic (i.e., 3. In subjects at risk of heart disease, usually >40 years old electrolyte disturbance, effect of drugs) changes are made by without evidence of but with two or inference and are, therefore, subject to error. The data that more of the following risk factors: hypercholesterolemia, allow for a diagnosis by inference were derived from extensive diabetes, obesity, smoking or positive family history. In this studies correlating the ECG with a variety of clinical patho- group, frequent follow-up recordings are usually not indi- logic and experimental states. cated unless signs or symptoms of heart disease appear. It is also important to recognize that the same ECG pattern 4. In selected subjects with fewer risk factors whose occupa- may be recorded with different structural and pathophysiologic tions magnify the consequences of a heart attack or arrhyth- states. This explains the frequent low specificity for etiology mia, for example, commercial airline pilots or bus drivers. and anatomy. For example, although ST segment and 5. Before surgical intervention as an aid in the diagnosis and changes are the most common and most sensitive ECG management of preoperative conditions or subsequent abnormalities, these changes are at the same time the least postoperative complications. However, it should be empha- specific (2,3). Similarly, different etiologic factors and struc- sized that definitive data regarding the utility of electrocar- tural abnormalities may result in an identical form of bundle diography as a routine baseline preoperative procedure are branch block. not available (6). It is obvious from the foregoing that the sensitivity and 6. For assessing cardiac effects of systemic diseases or condi- specificity of the ECG depends to a large extent on the clinical tions, such as renal failure, diabetic acidosis and hypother- question asked. Although the sensitivity and specificity of the mia, electrolyte abnormalities and potential cardiotoxic ECG for myocardial disorders vary considerably depending on effects of drugs. the cause, size and location of the pathologic process, the sensitivity and specificity for arrhythmias are consistently high. Electrocardiography is not cost-effective as a screening The ECG is the only practical method for recording and procedure for cardiovascular disease or as a baseline study in analyzing abnormalities of cardiac rhythm and conduction. asymptomatic healthy subjects without symptoms or signs of heart disease, hypertension or other risk factors for develop- ment of heart disease (7-10). A statement of the indications Justification for Recommendations for electrocardiography was published by the American Col- The indications, contraindications and recommendations for lege of Cardiology and the American Heart Association (11) in the minimal education, training, experience and skills necessary to March 1992. perform the procedure are derived principally from the 17th Although there are no complications resulting from the Bethesda Conference on adult cardiology training (4)* and the technique itself, inappropriate interpretation; lack of appreci- ation of the importance of sensitivity, specificity and predictive value; and failure to correlate the ECG findings with the *The 17th Bethesda Conference was recently updated and published as the overall clinical picture may result in serious iatrogenic heart first Core Cardiology Training Symposium, which includes Task Force 2: Electrocardiography, Ambulatory Electrocardiography and Exercise Testing disease. For example, an abnormal T wave is often equated (J Am Coil Cardiol 1994;25:l-34). with "," when in fact the specificity of an abnormal T JACC Vol. 25, No. 6 FISCH ET AL 1467 May 1995:1465-9 ACP/ACC/AHA TASK FORCE STATEMENT wave for any one cause (i.e., ischemia) is low (2,3). Further- successfully pass the examination are competent in ECG more, moderate T wave inversion predicts an annual mortality interpretation. rate of 21% when associated with a history of heart disease On occasion, a physician may become competent in the compared with only 3% in the absence of heart disease (12). interpretation of ECGs by attending well designed courses Thus, a Y wave abnormality is of clinical value only when coupled with studies of unknown recordings available in stan- interpreted in light of the total clinical picture and other dard texts and by interpreting large numbers of recordings laboratory results. under the supervision of a physician knowledgeable in electro- cardiography. Simply attending courses that offer little oppor- tunity for testing individual interpretation of the ECG will not Computer Interpretation of the ECG result in competence. It is evident that although formal teaching of electrocardio- Because of frequent and often significant errors of inter- graphy as a part of a fellowship in cardiology or an internal pretation and lack of reproducibility of the interpretation, it is medicine residency is the best approach to becoming compe- mandatory in the clinical setting that all computer-interpreted tent in reading ECGs, competence can occasionally be attained ECGs be verified and appropriately corrected by an experi- by routes other than those followed during a residency or enced electrocardiographer. fellowship. For this reason, applicants for privileges to read ECGs may have to be evaluated on the basis of their actual cognitive knowledge rather than on the basis of the structure of Minimal Training Necessary for Competence the training. When the competence of a physician requesting There are a number of different routes by which a physician privileges is not clear, monitoring the candidate's interpreta- can acquire the necessary interpretive skills to recognize the tions or administration of a test may be appropriate. clinically important features of an ECG test (see Appendix). The cornerstone of training is interpretation of a large number Maintenance of Competence of ECGs and review of the interpretations with an experienced faculty. In addition to rotations on an ECG service, training Although continuing competence of ECG interpretation re- can be obtained in a wide variety of settings, which may include quires regular reading, this alone may not ensure competence. intensive care unit assignments, classroom work and didactic Furthermore, there are no data that document a correlation sessions. The ECG interpretations, clinical correlations and between the frequency of unsupervised ECG interpretations and clinical integration essential for proper ECG training must be the desired skill. Therefore, as a part of quality assurance under the supervision of physicians qualified to teach electro- programs, a random sample of ECG interpretations by the cardiography. physician requesting continuing privileges should be reviewed There are no studies that define the minimal number of periodically by independent experts to confirm continued compe- ECGs that must be read during the training program to attain tence. The recordings in question should be reviewed by physi- competence; however, some survey data are available. The cians experienced in ECG interpretation. If no one within the American College of Physicians (ACP) surveys of internal hospital is qualified to investigate a candidate's experience, then medicine residency program directors, general internists and an outside qualified expert should be consulted. cardiologists asked respondents to estimate the number of The American College of Cardiology has developed and procedures needed to attain competence. The median number field-tested a self-assessment program in electrocardiography recommended by both program directors and general inter- that is available through the College's office in Bethesda, nists was 100; the median number recommended by cardiolo- Maryland. gists was 750 (13). The recommendation of the Seventeenth Bethesda Conference is that cardiology fellows read 3,500 Appendix ECGs (4). This Task Force recommends the interpretation and review of 800 procedures within a 3-year training period under Electrocardiographic Items the supervision of an experienced faculty. The ECGs should Technique reflect a wide variety of clinical situations and ECG abnormal- Proper electrode placement ities (see Appendix). Correct standardization Although many physicians acquire the cognitive skills Proper frequen~ response needed for proper interpretation of the ECG during a fellow- Proper paper speed Effect of age, weight and body build ship or a residency program, completion of a fellowship or Muscle tremor and other artifacts residency does not guarantee competence. Some training Normal electrocardiogram (ECG) programs do not include structured teaching of electrocardio- QRS axis, rotation, position graphy. The requirement by the American Board of Internal Left-axis deviation (<-30 °) Medicine Subspeciality Board on Cardiovascular Disease that Right-axis deviation (> + 100°) Electrical alternans the candidate successfully pass the ECG component of the Clockv, ise, counterclockwise rotation examination before being certified implies that those who Vertical, horizontal, intermediate position 1468 FISCH ET AL. JACC Vol. 25, No. 6 ACP/ACC/AHA TASK FORCE STATEMENT May 1995:1465-9

Sinus node rhythm Combined (biventricular) Normal Intraventricular conduction disturbances Sinus Right Sinus Incomplete Sinus Complete Sinus pause or arrest Rate related Sinoatrial exit block Left anterior fascicular block Atrial rhythm Left posterior fascicular block Atrial premature complexes Blocked Incomplete Chaotic atrial rhythm Complete Rate related Atrial tachycardia with atrioventricular (AV) block Nonspecific interventricular block Peri-infarction block Atrial Pre-excitation (Wolff-Parkinson-White syndrome) Any of the above with aberration Myocardial infarction Septal Junctional rhythm (passive) Anteroseptal AV junctional premature complex Anterior AV junctional escape complex or rhythms Lateral Junctional parasystole AV nonparoxysmal High lateral AV node reciprocating tachycardia (reentrant) Extensive anterior Junctional tachycardia with block Inferior AV reciprocating tachycardia (Wolff-Parkinson-White syndrome) Posterior Any of the above with aberration Right ventricular Supraventricular tachycardia (not otherwise identified) Non-Q wave infarction Wide QRS tachycardia Acute injury and/or infarction Supraventricular with aberration Old Ventricular Age undetermined Ventricular rhythm Probable ventricular aneurysm Ventricular premature complexes Atrial infarction Uniform, with fixed coupling, single or couplets ST, T, QT, U wave changes Multifocal, multiform Normal variant R or T wave phenomenon Early repolarization Interpolated Juvenile T waves Ventricular Nonspecific ST and/or T wave changes Ventricular parasystole ST and/or T wave changes Suggestive of myocardial ischemia Bidirectional Suggestive of acute Accelerated idioventricular rhythm Suggestive of an acute process Ventricular escape complex or rhythm Prolonged QT interval Short QT wave Prominent U waves Torsade de pointes Negative U waves Reciprocal (echo) complexes Pacemaker Fusion complexes Capture complexes Normal function AV conduction Abnormal function AV block ECG patterns suggestive of clinical diagnosis First degree Hypertrophic Second degree Dextrocardia Type I (Wenckebach) Long QT syndrome Type II (Mobitz) Mitral stenosis High degree Ccrebrovascular accident Complete Chronic lung disease Paroxysmal Pericarditis, acute Ventriculoatrial conduction Pericardial tamponade AV dissociation Pulmonary embolus Hypertrophy, enlargement Hyperthermia Right Hypothermia Left atrial enlargement Hypercalcemia Biatrial enlargement Hypocalcemia Left ventricular hypertrophy Hyperkalemia Voltage only Hypokalemia Voltage and ST-T wave changes Antiarrhythmic drugs Right ventricular hypertrophy Digitalis effect JACC Vol. 25, No. 6 FISCH ET AL. 1469 May 1995:1465-9 ACP/ACC/AHA TASK FORCE STATEMENT

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